Provider Demographics
NPI:1912424979
Name:OSBORNE, LARA C (LISW)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:C
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5790 STILLWELL BECKETT RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45056-8931
Mailing Address - Country:US
Mailing Address - Phone:773-732-0749
Mailing Address - Fax:
Practice Address - Street 1:5790 STILLWELL BECKETT RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-8931
Practice Address - Country:US
Practice Address - Phone:773-732-0749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161773101YA0400X
INC2-5173101YA0400X
OHI.21031941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0399794Medicaid